Giancarlo A. Garcia

Surgical and Functional Outcomes in Patients Undergoing Total Knee Replacement With Patient-Specific Implants Compared With “Off-the-Shelf” Implants:

Background Total knee arthroplasty (TKA) instrumentation and implant designs have been evolving, with one of the current innovations being patient-specific implants (PSIs). Purpose To evaluate whether there is a significant difference in surgical time, intraoperative blood loss, postoperative range of motion, and length of stay between PSI and conventional TKA. Study Design Cohort study; Level of evidence, 3. Methods A consecutive series of 621 TKA patients, 307 with PSIs and 314 with conventional implants, was reviewed. Differences in estimated blood loss, length of stay, range of motion, and surgical time/tourniquet time between the 2 cohorts were analyzed. Results Linear regression analysis demonstrated that PSI decreased estimated blood loss by 44.72 mL (P < .01), decreased length of stay by 0.39 days (P < .01), decreased postoperative range of motion by 3.90° (P < .01), and had a negligible difference on surgical and tourniquet time. Conclusion The use of PSI is associated with decreased estimated blood loss, decreased length of stay, decreased range of motion, and no discernible difference in surgical or tourniquet time, all of which are unlikely to be clinically significant.

Profound vision loss impairs psychological well-being in young and middle-aged individuals

Purpose The aim of this study was to evaluate the effects of profound vision loss on psychological well-being in adolescents, young adults, and middle-aged adults with regard to mood, interpersonal interactions, and career-related goals. In addition, we assessed the significance of the resources that may be used to enhance psychological well-being in cases of profound vision loss, and in particular, examined the utility of low vision aids and the role of the ophthalmologist as a provider of emotional support. Methods A questionnaire was issued to individuals aged 13–65 years with profound vision loss resulting from Leber’s hereditary optic neuropathy (LHON). Depression prevalence was evaluated with questions regarding major depressive disorder symptomatology. Participants appraised the effects of vision loss on their interpersonal interactions and career goals by providing an impact rating (IR) on a 21-point psychometric scale from −10 to +10. Social well-being index was defined as the average of interpersonal IR and career IR. Subjects were additionally asked about the use of low vision aids and sources of emotional support. Results A total of 103 participants (mean age =26.4±11.2 years at LHON diagnosis; mean ± standard deviation) completed the questionnaire. Nearly half (49.5%) met the depression criteria after vision loss. Negative impacts on interpersonal interactions (median IR = −5) and career goals (median IR = −6) were observed; both ratings were worse (P<0.001) for depressed versus nondepressed subjects. Older age at diagnosis corresponded to higher depression prevalence and increased incidence of negative interpersonal IR and career IR. Sixty-eight percent of subjects used electronic vision aids; controlling for age, social well-being index was higher among these individuals than for those who did not use electronic aids (P=0.03). Over half of the participants (52.4%) asserted that they derived emotional support from their ophthalmologist. Conclusion Profound vision loss in adolescents, young adults, and middle-aged adults is associated with significant negative psychological and psychosocial effects, which are influenced by age and use of electronic vision aids. Ophthalmologists, in addition to managing vision loss, may serve an important role in the emotional adaptation of these patients.

Comparison of 2 pupil expansion devices for small-pupil cataract surgery

UNLABELLED We compared the degree of postoperative iris distortion with the diamond-shaped Malyugin ring and the circular Visitec I-Ring iris dilators using postoperative iris photographs in a patient with bilateral small nondilating pupils. Routine phacoemulsification was performed in the right eye with the assistance of a Malyugin ring for iris dilation. One month later, the same procedure was performed in the left eye using the circular ring for iris dilation. Anterior chamber slitlamp photographs were taken of both eyes. The amount of distortion in the postoperative pupils was calculated using the ratio of the postoperative pupil area to the area of the circle of best fit. The circular ring, constructed from a softer material, resulted in 11% distortion and the Malyugin ring, 49%, suggesting that the circular ring caused less trauma to the iris. FINANCIAL DISCLOSURE None of the authors has a financial or proprietary interest in any material or method mentioned.

Malignant Orbital Meningioma Originating from the Frontal Lobe.

Purpose of the Study: Orbital meningiomas are typically benign tumors, most commonly originating from the dura of the sphenoid wing or the optic nerve sheath. Procedures: We describe an unusual case of a malignant meningioma originating from the frontal lobe that ultimately produced orbital and distant metastases. Results and Conclusions: Orbital invasion by the meningioma was preceded by multiple incomplete resections, which may have facilitated access to the orbit. The present case serves to remind clinicians that surgical resection of aggressive, recurrent frontal lobe meningiomas may facilitate subsequent penetration of surrounding structures, particularly by tumors that demonstrate bone-destructive properties.

Management of Ocular Surface Disease in Cataract and Refractive Surgery Patients

The integrity of the ocular surface is paramount for proper vision. The ocular surface is a delicate microenvironment susceptible to a variety of insults. Small changes can have a large impact on visual function. The pathophysiology of OSD is multifactorial; treatment of OSD therefore typically requires a multifaceted approach for effective management. Thorough evaluation of ocular surface and eyelid health is of critical importance in cataract and refractive surgery candidates. Relatively simple diagnostic techniques and treatments may effectively determine the difference between a satisfied and unsatisfied patient postoperatively. Comorbid OSD increases the risk of complications and can impair surgical outcomes. Thus, preoperative signs and symptoms of OSD must be managed aggressively. Cataract and refractive surgery should be delayed until the patient demonstrates objective evidence of improvement, with reliable and repeatable preoperative measurements. Patients should be encouraged to adhere to the prescribed treatment regimen, and certain cases can require several months of preoperative therapy. OSD may also influence intraoperative management of patients and guide selection of postoperative eye drop regimens and follow-up care. Meticulous attention to the health of the ocular surface is essential to optimize the surgical result, ensure patient satisfaction, and enhance vision-related quality of life.

Baby Shampoo Versus Povidone-Iodine or Isopropyl Alcohol in Reducing Eyelid Skin Bacterial Load.

PURPOSE Baby shampoo is used as an alternative surgical skin preparation, but the evidence supporting its use is scarce with no descriptions of efficacy in the periocular region. The authors compare the efficacy of baby shampoo, povidone-iodine (PI, Betadine) and isopropyl alcohol (IA) in reducing eyelid skin bacterial load. METHODS Prospective, randomized, comparative, and interventional trial. Bacterial load on adult, human eyelid skin was quantitated before and after cleansing with 1) dilute baby shampoo, 2) 10% PI, or 3) 70% IA. Paired skin swabs were collected from a 1 cm area of the upper eyelid of subjects before and after a standardized surgical scrub technique. Samples were cultured on 5% sheep blood agar for 24 hours. The number of colony forming units (CFU) was assessed and bacterial load per square centimeter of eyelid skin was quantified. RESULTS Baseline and postcleansing samples were assessed from 42 eyelids of 42 subjects (n = 14 for each of baby shampoo, PI, and IA). Before cleansing, similar amounts of bacterial flora were grown from all specimens (median log CFU/cm = 2.04 before baby shampoo, 2.01 before PI, 2.11 before IA; p > 0.05). All 3 cleansing agents significantly reduced the bacterial load (p < 0.01 for each). There was no statistically significant difference in postcleansing bacterial load between the 3 cleansing agents (median log CFU/cm = 0.48 after baby shampoo, 0.39 after PI, 0.59 after IA; p > 0.05). Change from baseline in bacterial load was statistically similar for all 3 agents (median reduction in log CFU/cm = 1.28 with baby shampoo, 1.57 with PI, 1.40 with IA; p > 0.05). These corresponded to bacterial load reductions of 96.3%, 96.6%, and 98.4% for baby shampoo, PI, and IA, respectively. CONCLUSIONS Baby shampoo achieved comparable diminution in eyelid skin bacterial load to PI or IA. These data suggest baby shampoo may be an effective preoperative cleansing agent.

Upper Eyelid and Pupillary Effects of Topical Dilute Epinephrine.

PURPOSE Adrenergic medications may elevate the upper eyelid and dilate the pupil. The effects of topical phenylephrine on Müllers muscle have been well described. Dilute epinephrine (DE) is a sympathomimetic agent commonly administered in blepharoptosis surgery, and has been shown to elevate the upper eyelid margin when injected subcutaneously. The effects of DE applied topically to the eye, whether intentional or inadvertent during surgery have not been characterized. The purpose of this investigation was to quantify and compare the effects of topical DE and phenylephrine on upper eyelid position and pupil size. METHODS Prospective, nonrandomized trial of 41 adults without (n = 25, 25 eyes) and with ptosis (n = 16, 16 eyes). Upper eyelid margin reflex distance (MRD1) and pupil diameter were primary measures and pupil reactivity to light was a secondary measure. MRD1 and pupil diameter were recorded at baseline and at 30-second intervals for 5 minutes after administration of topical 1% lidocaine with epinephrine 1:100,000 (DE). After a washout period of >24 hours, the same measurements were recorded after administration of topical phenylephrine 2.5%. RESULTS No statistically significant difference was observed between mean baseline and postexposure MRD1 after application of topical DE (p = 0.181). In contrast, a mean increase in MRD1 of 0.51 ± 0.09 mm (effect size 0.33) was observed after exposure to phenylephrine 2.5% (p < 0.001). Baseline-adjusted postexposure mean MRD1 was significantly greater for phenylephrine compared with DE (p < 0.001, analysis of covariance). Mean pupil diameter increased 0.29 ± 0.09 mm (effect size 0.48) in response to DE and 0.27 ± 0.11 mm (effect size 0.41) after application of phenylephrine (p = 0.004 and p = 0.001, respectively). All pupils maintained a constrictive response to light. CONCLUSIONS Although DE is similar to topical phenylephrine in causing mydriasis, it did not have a similar effect on elevating the upper eyelid. These findings may have implications on intraoperative assessment during eyelid surgery. The pupillary changes due to DE offer one explanation for cases of transient pupil dilation during orbitofacial surgery.

Validity of Forced Eyelid Closure Test: A Novel Clinical Screening Test for Ocular Myasthenia Gravis

Background: Forced eyelid closure test (FECT) is a clinical screening test developed from the original Cogan lid twitch (CLT) sign to assist in the diagnosis of ocular myasthenia gravis (OMG), We evaluated the sensitivity and specificity of FECT compared with CLT and benchmarked to standard diagnostic tests. Methods: This study was a retrospective chart review of 48 patients using electronic medical records of those that presented with ptosis and/or diplopia at Doheny Eye Institute, University of California, Los Angeles between February 2015 and April 2016. Patients without FECT testing were excluded. FECT and CLT results, and final diagnosis were recorded. To perform FECT, the patient was asked to squeeze his or her eyelids shut for 5–10 seconds then open quickly and fixate in primary position. The excessive upward overshoot of eyelids movement indicated a positive FECT. The test was performed by a neuro-ophthalmologist before establishing the diagnosis. Patients who had equivocal test results and/or inconclusive final diagnosis were excluded. Results: Of the 48 patients studied, 18 patients (37.5%) had positive FECT; 15 of whom had a final diagnosis of OMG (83.3%). Of the 30 patients with negative FECT, 1 had OMG (3.3%). Of the 48 patients, 35 patients also had a documented CLT result (72.9%). CLT was positive in 11 of these 35 patients (31.4%), and 9 of these 11 had OMG (81.8%). Of the 24 patients with negative CLT, 2 of them had OMG (8.3%). Sensitivity and specificity of FECT were 94% and 91% (joint 95% confidence region: sensitivity × specificity = [0.70, 1] × [0.75, 1]). The relative true-positive fraction (rTPF) between FECT and CLT was 1.15; the relative false-positive fraction was 1.31. Conclusions: FECT is a simple clinical screening test with good sensitivity and specificity for OMG.

Lazy Pentagonal Wedge Resection of Eyelid Margin Lesions

Full-thickness pentagonal wedge resection and repair is a mainstay in the treatment of eyelid neoplasms, trichiasis, and other eyelid pathologic abnormalities.1-3 Traditionally, when performed on the lower eyelid, incisions are made in a symmetric pentagon surrounding the lesion. The parallel vertical medial and lateral incision design offers structural integrity of the reconstructed tarsus and margin and forestalls eyelid margin distortion and notching. Fullthickness resection may also more reliably eradicate basal cell carcinoma (BCC) and other carcinomas. However, the largely vertical wound may leave a conspicuous scar as it crosses normal horizontal or oblique relaxed skin tensions lines. The triangular inferior aspect of the defect may add to the resultant deformity since it induces skin redundancy, known as a dog-ear deformity, that usually requires additional surgical treatment.3-6 A modified curvilinear or “lazy” pentagonal wedge resection technique may achieve the tarsal alignment associated with the pentagonal wedge, yet minimize scarring and dog-ear deformity. In this procedure, this curved pattern—in lieu of a linear incision—may minimize cutaneous excess and keep the resultant wound aligned with the relaxed facial skin tension lines. Herein, we describe this surgical technique in detail and retrospectively assess safety outcomes and cosmetic results.